| NPI | 1053373175 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 21380) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 0021380) |
| Enumeration Date | 2006-04-04 |
| Last Update Date | 2014-10-01 |